Rheumatoid arthritis (RA) is a chronic multi-systemic autoimmune inflammatory disease where the immune system attacks healthy cells, resulting in the painful swelling in affected parts of the body. Rheumatoid arthritis usually attacks multiple joints all at once.
What is rheumatoid arthritis?
Rheumatoid arthritis develops when a genetically predisposed individual experiences a trigger that causes an autoimmune reaction. The specific causes are unknown but environmental triggers such as infection, trauma and cigarette smoking can contribute to disease onset.
In rheumatoid arthritis, the immune system attacks healthy cells in the body by mistake to cause painful swelling in affected body parts. It occurs in joints that are lined by a synovial membrane.
In rheumatoid arthritis, the lining of the joint becomes inflamed and persistent damage to joint tissues causes chronic pain that can cause issues with balance, especially in the knees.
Rheumatoid arthritis can also affect other organs such as the skin, heart, kidneys, salivary glands, nerves, bone marrow and lungs.
Signs and symptoms
The hallmark feature of rheumatoid arthritis is symmetric polyarthritis of the hands and feet. This means that there is symptomatic pain that develops in the same area on both sides of the body. For example, pain is experienced in both hands. Other symptoms that are commonly present include:
- Aching pain in more than one joint
- Stiffness
- Tenderness of more than one joint
- Weakness
- Fatigue
- Progressive articular deterioration presenting (difficulty in mobility)
- Issues in carrying out daily tasks
- Extra-articular involvement
- Limitation of motion
- Rheumatoid nodules
Diagnosis
Rheumatoid arthritis may be difficult to diagnose as early signs correlate to other disease manifestations. A combination of laboratory and imaging features are necessary in confirming diagnosis. Laboratory studies that can help diagnosis via blood tests include:
- Rheumatoid factor assay
- Antinuclear antibody (ANA) assay
- Anti-cyclic citrullinated peptide (anti-CCP) antibodies
- Increased C-reactive protein (CRP) levels
- Elevated erythrocyte sedimentation rates (ESR)
Imaging studies
The radiographic hallmarks of rheumatoid arthritis are narrowing of joint spaces, marginal erosions of the synovial membrane and any swelling of soft tissue. Ultrasound and MRI are two imaging modalities that are more helpful than radiography.
- An ultrasound can help to visualise the degree of vascularisation of the synovial membrane
- Magnetic resonance imaging is primarily used to observe damage to the cervical spine
- Radiography of the knees, hands, shoulders and other joints is also commonly conducted
Early diagnosis and treatment of rheumatoid arthritis within the first 6 months of the onset of symptoms can help to slow disease progression and prevent further deterioration and damage of joints.
Complications of rheumatoid arthritis
Osteoporosis
Medications for rheumatoid arthritis can increase the risk of developing osteoporosis, a disease where bones become weak and brittle, making one prone to fractures.
Carpal tunnel syndrome
Rheumatoid arthritis affecting the wrists can lead to inflammation of the nerves that control the hands and fingers.
Heart disease
Patients have a 50-70% increased risk of cardiovascular problems as compared to healthy individuals. They face an increased risk of hardened and blocked arteries, including pericarditis which is the inflammation of the thin membrane that surrounds the heart. This means that patients become more susceptible to premature heart disease – heart disease before age 55 for a man and before 65 for a woman.
Lymphoma
Patients with rheumatoid arthritis also face double the average risk of developing lymphoma (blood cancer that develops in the lymph system), mainly due to excessive chronic inflammatory stimulation. This includes Hodgkin lymphoma, non-Hodgkin lymphoma and diffuse large B cell lymphoma.
Treatment of rheumatoid arthritis
Patients are usually treated with medications that help to slow disease progression and decrease risk of joint deformity. These can include:
NSAIDs
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen help to relieve pain and reduce inflammation. However, side effects such as stomach irritation may occur with long-term use.
Disease-modifying anti-rheumatic drugs (DMARDs)
DMARDs such as methotrexate and sulfasalazine are immunosuppressants that help to slow disease progression and prevent damage of tissues. Gastrointestinal problems such as nausea and vomiting are the most common side effects that affect up to 65% of RA patients. Ulceration and sores are also common. Patients also risk lung damage when taking this drug.
Surgery
Surgery may be recommended in patients with more severe forms of the disease where mobility has been reduced significantly.
Total joint replacement surgery involves removing damaged parts of the joint and replacing those parts with a prosthesis to facilitate movement.
Tendon repair surgery is recommended when there is excessive wear and tear of the damaged joint that has caused neighbouring tendons to lose their function.
Removal of the lining of the joint that has become inflamed may also help to relieve pain in the patient and allow for better mobility.
Management Strategies
Keeping active can help to decrease pain and improve function. Maintaining a healthy weight can also help to reduce stress load on the knees.
